Medication Management Who are we talking about? Older adults are a heterogenous group! Patricia W. Slattum, PharmD, PhD Professor of Pharmacotherapy and Outcomes Science Director, Geriatric Pharmacotherapy Program Medications: The Right Balance Medications are probably the single most important health care technology in preventing illness and disability in the older population. "Any symptom in an elderly patient should be considered a drug side effect until proven otherwise." Geriatric Syndromes Clinical conditions in older persons that do not fit into exact disease categories Geriatric syndromes include: Falls Delirium Frailty Dizziness Syncope Urinary incontinence Avorn J. Health Affairs, Spring 1996; J Gurwitz, M Monane, S Monane, J Avorn. Brown University Long-term Care Quality Letter 1995 Inouye SK, Studenski S, Tinetti ME, Kuchel GA. JAGS 2007;55:780-91 Sleeper RB. Consult Pharm 2009;24:447-462. 1
Geriatric Syndromes Highly prevalent, especially in frail older adults Substantially impact quality of life and disability Caused by multiple underlying factors Challenge the traditional way of viewing clinical care Can be mistaken for normal aging May be caused or worsened by medications Inouye SK, Studenski S, Tinetti ME, Kuchel GA. JAGS 2007;55:780-91. Sleeper RB. Consult Pharm 2009;24:447-462. Drug Pharmacokinetics, Pharmacodynamics and Aging PK Concentration in the Circulation Absorption Distribution Metabolism Excretion PD Drug Effect Drug-receptor interactions Concentration at receptor Homeostatic mechanisms Efficacy Desirable Therapeutic Outcome disease characteristics adherence Medication Use Process What is a Medication- Related Problem? An undesirable event experienced by a patient that involves or is suspected to involve drug therapy and actually or potentially interferes with a desired patient outcome. 2
Risk Factors for Medication-Related Problems More than 6 current medical diagnoses More than 12 doses of medications per day 9 or more total medications History of adverse drug reactions in the past Low body weight Age 85 years Low kidney function Fouts M, et al. Consult Pharm 1997;12:1103-11 Risk Factors for Adverse Drug Events in Outpatients PATIENT CHARACTERISTCS Polypharmacy Dementia Multiple chronic diseases CrCl < 50 ml/min Recent hospitalization Age 85 years Multiple prescribers Regular use of alcohol (> 1 fl oz/d) Prior ADR Hajjar ER, et al. Am J Geriatr Pharmacother 2003;1:82 9) Other Factors Contributing to Medication- Related Problems in Older Adults Changes in the body that occur with aging Multiple prescibers Limited evidence base Limited health professional expertise in aging Symptoms of a Medication-Related Problem in Older Adults Altered mental status/confusion Fatigue Falling Constipation Blurred vision Depression Dizziness 3
Types of Medication-Related Problems Inappropriate Prescribing Polypharmacy Underuse Adverse Drug Events Drug Interactions Non adherence http://www.merckmanuals.com/professional/sec23/ch341/ch341e.html Inappropriate Prescribing for Older Adults Inappropriate prescribing defined as: Prescribing of meds where the potential risk outweighs the potential benefit Prescribing that does not agree with accepted medical standards Approaches to measure inappropriate prescribing: Drugs to avoid Clinical review using explicit criteria Hanlon JT et al. JAGS 2001; 49:200-209 Inappropriate Prescribing for Older Adults Drugs to avoid in older adults: The Beers criteria Developed by an expert consensus panel First published in 1991 for nursing home patients Updated in 1997 to apply to older adults in all clinical settings. Updated in 2003, 2012 and 2015. Included severity rating reflecting the likelihood of an adverse outcome & the clinical significance of the outcome for each prescribing concern http://geriatricscareonline.org/productabstract/american-geriatrics-society-updated-beerscriteria-for-potentially-inappropriate-medication-use-in-older-adults/cl001 4
Applying Multiple Practice Guidelines to the Care of the Complex Older Adult Patient Most clinical practice guidelines are: Based on clinical evidence and expert consensus Designed by specialty dominated committees Focused on single diseases (almost never address more than 2) Lacking sufficient evidence regarding our oldest old patients Lack discussion of burden on patients and caregivers Do current CPGs provide an appropriate, evidencebased foundation for assessing quality of care in older adults with several chronic diseases? http://www.americangeriatrics.org/health_care_professionals/clinical_practice/multimorbidity Overuse of Medication Polypharmacy defined as: Concurrent use of multiple medications Administration of more medications than are needed Hanlon JT et al. JAGS 2001; 49:200-209 Overuse of Medication Prescribing Cascades Overuse can also occur when: Doses are too high Unintentional duplicate therapies are prescribed Two drugs of the same class are prescribed for high blood pressure Two medications prescribed for sleep by different doctors DRUG 1 Adverse Event Misinterpreted as New Medical Condition DRUG 2 Rochon PA, Gurwitz JH. BMJ 1997;315:1096-9. Adverse Drug Event 5
Underuse of Medications Omission of drug therapy that is needed for the treatment or prevention of a disease or symptom. Ex: Pain management Hanlon JT et al. JAGS 2001;49:200-9; Lipton HL et al. Ann Rev Gerontol Ger 1992; 12:95-108; Cherubini A, et al. Drugs Aging 2012; 29:463-475 Adverse Drug Events Unwanted effects of medications or side effects More common in older adults May be mistaken for normal aging or new medical conditions Can occur when first starting a new medication or after taking a medication for a long time. Drug Allergies An allergy is an overreaction by the body s immune system to a foreign substance, such as a drug. Less than 10% of adverse drug events are drug allergies. Reactions can range from a mild skin rash to a life threatening emergency (usually difficulty breathing). It is very important to recognize drug allergies! Pay Close Attention to High Risk Drugs Medication use leading to ER visits 3.6% due to Beer s list drugs 33.3% due to warfarin, insulin and digoxin Emergency hospitalization due to ADEs Half among those 80 years 67% due to warfarin, insulin, antiplatelet agents and oral hypoglycemic agents 1.2% due to Beer s list drugs Ann Intern Med. 2007;147:755-765; N Engl J Med 2011;365:2002-12 6
More Evidence on High Risk Drugs ADEs among hospitalized Medicare recipients 8.2% of patients exposed to warfarin 13.6% exposed to heparin 10.7% exposed to insulin/hypoglycemic agents 0.5% exposed to digoxin Joint Commission Journal on Quality and Patient Safety 2010;36:12-21 Drug Interactions Prevalence increases as number of prescribed drugs increases 5 to 7 drugs = 4 fold greater risk 8 to 10 drugs = 8 fold greater risk Can t prevent all drug interactions Patient groups at increased risk older adults those seeing multiple prescribers those being infrequently or inadequately monitored those with impaired pathways of drug elimination those with certain pharmacogenetic patterns Mallet L, et al. Lancet 2007;370:185-91. http://www.fda.gov/downloads/forconsumers/consumerupdates/ucm096391.pdf Role of Alternative Medicines? OTC Products and Older Adults Sedating antihistamines Decongestants Nonsteroidal antiinflammatory drugs Acetaminophen Acid suppressing drugs http://www.nyam.org/agefriendlynyc/docs/otc list for pharmacists NYAM.pdf 7
Drug Food Interactions As a rule, drugs are absorbed better when taken with water. Acidic fruit juices, vegetable juices, carbonated beverages, caffeinated beverages and milk products can interfere with the absorption of some drugs. Not taking enough fluids with medications can also delay drug absorption or cause stomach irritation. Medications should be taken with at least ½ cup of water unless patient has order for limited fluid intake. http://www.usatoday.com/story/news/nation/2013/01/20/fooddrug interactions/1827229/ Medication Adherence Causes of nonadherence Older adults may be more prone because of higher proportion of prescribed meds Poor patient-healthcare provider relationships Multiple providers Multiple pharmacies Almost 40% of seniors are unable to read a prescription label, and 67% are unable to understand information given to them. Vik SA et al. Ann Pharmacother 2004;38:303-12. McLaughlin et al. Drug Aging 2005;22:231-255. Crushing Medications Some medications are less effective if crushed or mixed with food, milk or juice. Some medications taste bad when crushed. Some medications may be harmful to the individual crushing them if the particles are accidentally inhaled. The pharmacist or prescriber can help to identify liquid or other dosage forms that can be more easily swallowed if necessary. Timing of Medication Administration There are some medications where timing is particularly critical: Insulin Medications for Parkinson s disease Pain medications Sleep medications Osteoporosis medications Alendronate (Fosamax ) Risedronate (Actonel ) Ibandronate (Boniva ) Pamidronate (Aredia ) 8
The Medication History An accurate medication history is important and can take some detective work to obtain! The current medication list should include: Prescription medications Over the counter medications Dietary supplements/herbal products Alcohol For each medication, record the dose, time(s) taken each day, frequency of use for as needed medications and indication. http://www.medsandaging.org/documents/personalmedlist_000.pdf Safely Discontinue Excess Meds Most medications can simply be discontinued without causing an adverse drug withdrawal event Following long term use, some drugs should be tapered slowly; days to weeks Benzodiazepines Antidepressants Other psychotropic drugs Beta blockers Bain KT, et al. JAGS 2008;56:1946 52. Preventing Medication Related Problems Improve communication between patient and health care providers, including ability to pay for medications. Designate a medication manager and have regular medication check ups. Keep a medication list and take all medications to appointments with doctors. Consult with a doctor or pharmacist before using over the counter medication or herbal supplements. Get all prescriptions filled at one pharmacy. Reducing the Caregiving Hassles of Medication Management Talk with your pharmacist Keeping up with refills Specialized packaging Knowing when medications can be crushed, mixed with food, etc. Planning a medication administration schedule that works with your daily routine Options for paying for medications Knowing why a medication is being given and what to expect The Gerontologist (2003)Vol. 43, No. 3, 360 368 9
Reasons MRPs may not be addressed in elderly patients My patient has been taking this medication for many years without a problem The balance between benefit and risk shifts as people age, due to physiologic changes associated with aging and chronic disease. The benefits and risks of each medication should be assessed regularly and alternatives with the lowest potential risk should be prescribed. McLeod PJ et.al. Can Med Assoc J 1997;156:385-91; Vestal RE. Cancer 1997;80:1302-10. Reasons MRPs may not be addressed in elderly patients I did not prescribe all of the medications my patient is taking Elderly patients medication management is often complicated by the fact that they seek medical care from multiple physicians, sometimes for the same medical problem. Review all medications at each visit and assist patients in designating a medication manager from among their providers to coordinate their care. Knight and Avorn. Ann Intern Med 2001;135:703-710; Chutka DS et.al. Mayo Clin Proc 1995;70:685-93. Reasons MRPs may not be addressed in elderly patients The risk of discontinuing the medication is greater than the benefit. Approximately 75% of chronic medication discontinuations result in no adverse outcomes. Adverse outcomes are most likely when several medications are discontinued simultaneously. Exacerbation of cardiovascular disease is the most common adverse outcome. Some medications require a gradual withdrawal to avoid physiologic withdrawal reactions. Hanlon JT et al. J Clin Epidemiol 1992;45:1045-51; Graves T et.al. Arch Intern Med 1997;157:2205-10; Davidson HE. Consult Pharm 1998;13:209-10. Reasons MRPs may not be addressed in elderly patients My patients resist changes in their drug therapy. Many of the common ailments that elderly patients seek a physician s care for have no cure. Patients often have the expectation that something be done and physicians often have the perception of needing to do something. Motivated patients can successfully withdraw with appropriate education and monitoring. Although patients may be resistant, they may greatly benefit from the change. Chutka DS et al. Mayo Clin Proc 1995;70:685-93; Cormack MA et.al. Br J Gen Pract 1994;44:5-8. 10
Reasons MRPs may not be addressed in elderly patients My patient is not experiencing adverse effects usually seen with this medication. Elderly patients may experience atypical adverse effects from medications including confusion, forgetfulness, loss of balance, falls, incontinence, constipation or fatigue. Other medications may be added to regimens to treat unrecognized adverse effects. Medications should be suspected whenever elderly patients experience new symptoms and signs. Chutka DS et al. Mayo Clin Proc 1995;70:685-93; Rochon PA and Gurwitz JH. BMJ 1997;315:1096-9. Improving the Quality of Medication Use in Elderly Patients: A Not So Simple Prescription Putting the pieces of the puzzle together to create a solution remains a formidable, but not insurmountable task.all the pieces of the puzzle lie before us; it remains for us to find a way to fit them together Jerry H. Gurwitz, M.D. Gurwitz JH, Arch Intern Med 2002; 162:1670-3 Quality Indicators for Appropriate Medication Use in Vulnerable Elders Indicator 1: Medication List The outpatient medication record of every physician and the hospital medication record should contain an up to date medication list, including over the counter medications. Indicator 2: Periodic Drug Regimen Review All vulnerable elders should have a drug regimen review at least annually. Indicator 3: Drug indication When a new drug is prescribed, a clearly defined indication should be documented in the record. Shrank, Polinski & Avorn. J Am Geriatr Soc 2007;55:S373-S382. Quality Indicators for Appropriate Medication Use in Vulnerable Elders Indicator 4: Patient Education When a new drug is prescribed, the patient or caregiver should receive education about the purpose, directions for use and important adverse reactions. Indicator 5: Response to Therapy Every new drug prescribed on an ongoing basis for a chronic medical condition should have a documentation of the response to therapy. Shrank, Polinski & Avorn. J Am Geriatr Soc 2007;55:S373-S382. 11
Summary Older adults are at risk for experiencing geriatric syndromes and medication related problems. Some of these problems are preventable! All members of the healthcare team, including the patient, contribute to the optimal use of medications. 12